We welcome the letter by Chen and Parikh (1) sharing their perspective on our study (2) and presenting their recent work on the association of the Affordable Care Act (ACA) Medicaid expansion with dilated eye exams (3).
Joint efforts by providers and patients are vital for successful diabetes management, and the ACA Medicaid expansion could expand the utilization of routine checkups for diabetes care. Through increased access to medical providers and increased attention to self-monitoring behaviors, we believe that the ACA could be leading to important improvements in diabetes management (4). In response to the integrated diabetes management strategy, our research identified diabetes care activities led by providers, such as doctor visits, HbA1c tests, and foot checks, as well as patients’ corresponding self-monitoring behaviors, such as self–blood glucose checks and self-foot checks, as key indicators for the possible impact of Medicaid expansion on diabetes care (5). While our set of indicators provides critical information about the ACA’s influence, Chen and Parikh (1) are right to point out that the influence of the ACA could vary depending on the specific indicator being evaluated. Even as our analyzed measures are common in primary care settings for diabetes and, thus, likely to be covered by insurance, Chen and Parikh provide an important caveat that certain specialties, like those performing eye exams, might be less likely to accept Medicaid and that our composite measure could be masking such differences. This point represents an important direction for future research by including further dimensions of diabetes management, such as eye exams and medications, that could be interesting to explore.
In addition, while Chen et al. (3) analyzed the Behavioral Risk Factor Surveillance System (BRFSS) from 2009, we used the BRFSS from 2011 through 2016 comparing diabetes care before and after the Medicaid expansion. Since 2011, the BRFSS has made major changes in its data collection methodology, including collection procedures, structure, and weighting. For these reasons, the Centers for Disease Control and Prevention highlight that data users should not link pre- and post-2011 data (6). This is a critical note for those interested in using the BRFSS. We agree with the general point raised by Chen and Parikh that testing for the diminishing impact of the ACA’s policy effects will be important as the ACA is ingrained into U.S. health policy. Our analysis of the 6 years surrounding the Medicaid expansion finds no evidence for this diminishing impact yet; however, it remains possible that patients who were pushed toward diabetes care after the ACA’s passage may not continue necessary follow-up care. Additionally, researchers need to recognize that diabetes care could be further transformed by future health reforms that could help or hinder patients’ abilities to get needed diabetes treatment.
We thank Chen and Parikh (1) for sharing important points. We agree that a diverse group of indicators need to be taken into account when evaluating policy effects and that exploring change over time is critical. Nevertheless, we believe our study represents an important step in understanding the effect of Medicaid expansion on individuals with diabetes in the management of their disease.
Duality of Interest. No potential conflicts of interest relevant to this article were reported.